S4107 Endoscopic Management of Appendiceal Orifice Polyps: A 5-Case Series Supporting First-Line Conservative Approach

Introduction: Appendiceal orifice polyps pose a rare but challenging clinical entity (0.08–0.4% of colonoscopies) with limited evidence-based management guidelines. Traditionally, surgical referral has been favored due to risks of incomplete resection, retained neoplastic tissue, and post-polypectomy appendicitis. Recent studies report endoscopic feasibility with an ∼80% success rate and 12% 1-year recurrence but with a notable risk of appendicitis, challenging this paradigm. However, clinical guidelines remain limited. We present a 5-case series supporting traditional endoscopic techniques as effective 1st-line therapy. Case Description/Methods: We retrospectively reviewed 5 cases of appendiceal orifice polyps identified during screening colonoscopy (2019–2021) at a single tertiary center. Mean patient age was 62 years (range 50–79); 60% men; 80% Hispanic. Mean polyp size was 3.8 cm. All procedures were performed by an experienced endoscopist using high-definition colonoscopy. Submucosal injection (ORISE or Eleview) was followed by hot snare polypectomy, with piecemeal resection for lesions >2 cm and routine prophylactic clipping, and elective prophylactic appendectomy was recommended. Surveillance colonoscopy occurred at 3–12 months. Endoscopic resection succeeded in 4 of 5 cases (80%). Case 1: Six cm tubular adenoma, piecemeal resection; developed interval appendicitis; appendectomy showed residual adenoma. Case 2: Three cm sessile serrated adenoma, resected with no recurrence. Case 3: Two cm pedunculated tubular adenoma, resected with long-term negative surveillance. Case 4: Four cm tubulovillous adenoma, complete resection, no recurrence. Case 5: Four cm sessile serrated adenoma, inadequate lift; referred for appendectomy. Histology revealed 2 tubular adenomas, 2 sessile serrated adenomas, and 1 tubulovillous adenoma; no high-grade dysplasia or malignancy. Mean follow-up was 18 months; no local recurrence occurred in successful endoscopic cases. No intraprocedural complications occurred; 1 delayed appendicitis was noted. Discussion: Endoscopic resection is a safe and effective 1st-line option for appendiceal orifice polyps, achieving 80% success and 0% recurrence with proper technique. Inability to achieve adequate lift remains a contraindication. We propose an algorithm prioritizing endoscopic resection when elevation and complete margins are feasible, reserving surgery for complex/non-lifting lesions. This approach minimizes morbidity, warranting further validation through prospective studies.